Provider Demographics
NPI:1679741805
Name:CORNERSTONE SERVICES, INC
Entity Type:Organization
Organization Name:CORNERSTONE SERVICES, INC
Other - Org Name:AUTUMN LAKE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-741-7042
Mailing Address - Street 1:777 JOYCE RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-1876
Mailing Address - Country:US
Mailing Address - Phone:815-741-7045
Mailing Address - Fax:
Practice Address - Street 1:3515 THEODORE ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-2884
Practice Address - Country:US
Practice Address - Phone:815-741-7045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNERSTONE SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-11
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000040105OtherIDPH LICENSE NUMBER
IL000040105OtherIDPH LICENSE NUMBER